HESI LPN
Fundamentals of Nursing HESI
1. What advice should the client be given if they are feeling dizzy upon standing after taking a diuretic for hypertension?
- A. Avoid standing up too quickly.
- B. Increase fluid intake to stay hydrated.
- C. Eat more salt to help retain fluids.
- D. Wear compression stockings during the day.
Correct answer: A
Rationale: The correct advice for a client feeling dizzy upon standing after taking a diuretic for hypertension is to avoid standing up too quickly. Diuretics can lead to orthostatic hypotension, causing dizziness upon sudden position changes. Increasing fluid intake can exacerbate the issue by further lowering blood pressure. Eating more salt might counteract the diuretic's effects but is not the primary intervention for orthostatic hypotension. Compression stockings are more relevant for venous insufficiency than for orthostatic hypotension.
2. A client with prostate cancer declines to discuss concerns after the provider discusses treatment options. What statement should the nurse make?
- A. I am available to talk if you should change your mind.
- B. It’s important to discuss your concerns with the provider.
- C. You need to make a decision about your treatment options.
- D. Your concerns will be addressed at a later time.
Correct answer: A
Rationale: Offering to talk later if the client changes their mind respects their current choice and keeps the dialogue open. Choice B is not the best response as it may pressure the client to share concerns. Choice C is incorrect as it imposes a decision on the client. Choice D does not acknowledge the client's feelings in the moment and postpones addressing concerns.
3. A client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?
- A. Musculoskeletal weakness
- B. Loss of appetite
- C. Increased heart rate during physical activity
- D. Left lower extremity tenderness
Correct answer: D
Rationale: The nurse should prioritize assessing left lower extremity tenderness as it could indicate deep vein thrombosis, a serious condition that requires immediate attention. Musculoskeletal weakness, loss of appetite, and increased heart rate during physical activity are important but not as critical as a potential thrombotic event that could lead to life-threatening complications. Deep vein thrombosis is a common risk for individuals on prolonged bed rest due to reduced mobility and blood stasis.
4. The patient is reporting an inability to clear nasal passages. Which action will the nurse take?
- A. Use gentle suction to prevent tissue damage.
- B. Instruct the patient to blow their nose forcefully to clear the passage.
- C. Place a dry washcloth under the nose to absorb secretions.
- D. Insert a cotton-tipped applicator into the back of the nose.
Correct answer: A
Rationale: When a patient reports an inability to clear nasal passages, the appropriate action for the nurse to take is to use gentle suction to prevent tissue damage. Suctioning helps remove excess mucus or secretions without causing harm to the nasal tissues. Instructing the patient to blow their nose forcefully (Choice B) may exacerbate the issue and cause discomfort or injury. Placing a dry washcloth under the nose (Choice C) is not an effective intervention for clearing nasal passages. Inserting a cotton-tipped applicator into the back of the nose (Choice D) is not recommended as it can be invasive and may cause injury or discomfort to the patient.
5. When assisting an 82-year-old client to ambulate, it is important for the LPN/LVN to realize that the center of gravity for an elderly person is in the
- A. Arms.
- B. Upper torso.
- C. Head.
- D. Feet.
Correct answer: B
Rationale: The correct answer is 'Upper torso.' In elderly individuals, the center of gravity tends to shift upwards towards the upper torso due to various factors such as changes in posture and muscle strength. Understanding this is crucial for safe ambulation as it helps in maintaining balance and stability. Choices A, 'Arms,' C, 'Head,' and D, 'Feet,' are incorrect. The center of gravity is not typically located in the arms, head, or feet. It is higher up in the body, specifically in the upper torso. Knowing the correct location of the center of gravity is essential for assisting elderly clients in ambulation effectively and preventing falls.
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